Advance Directive For Mental Health Treatment Page 4
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Treatment facility staff can help me by doing the following:
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Please check one of the following:
______ I give consent to receive Electric Shock Therapy (ECT).
______ I DO NOT give consent to receive Electric Shock Therapy (ECT).
Are there other special considerations you need while being treated?
(Consider including any other illnesses you may have, any dietary restrictions, or
other matters of concern.)
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While I am being treated, the following things will need to be taken care of
at my home:
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